前段玻璃体切割联合Cionni张力环在伴有前房玻璃体脱出的外伤性晶状体半脱位手术中的应用

Application of anterior vitrectomy combined with Cionni tension ring in traumatic lens subluxation surgery with anterior vitreous prolapse

目的探讨应用前段玻璃体切割、囊袋拉钩联合Cionni改良张力环(Cionni-modified capsular tension ring,MCTR)在伴有前房玻璃体脱出的外伤性晶状体半脱位手术中的有效性和安全性。方法伴有前房玻璃体脱出的外伤性晶状体半脱位患者16例(16眼),脱位范围在90°~120°7眼、>120°~180°5眼、>180°~270°4眼,其中合并虹膜根部离断3眼、express植入1眼、青光眼瓣膜阀植入1眼。根据前房玻璃体情况,行曲安奈德染色后经前房或睫状体平坦部行玻璃体切割术,连续环形撕囊后使用2~4个囊袋拉钩钩住撕囊边缘,稳定晶状体囊袋并使其居中,超声乳化白内障吸出、MCTR植入及巩膜层间缝合固定,晶状体囊袋内植入折叠人工晶状体(intraocular lens,IOL)。术后随访3个月,观察术后视力、术中术后并发症、前囊口、IOL位置、眼压情况。结果所有患者均顺利完成白内障吸出、MCTR及IOL植入;其中植入双钩MCTR 7眼,单钩9眼。术后视力>0.5者9眼,>0.3~0.5者4眼,>0.1~0.3者2眼,≤0.1者1眼,术后术眼最佳矫正视力与术前比较,差异有统计学意义(χ2=17.503,P=0.000)。Pantacam眼前段分析系统获得Scheimpflug图像分析IOL居中性好,无MCTR及IOL移位等并发症发生。术中术后并发症有皮质残留、房水后部返流综合征、前囊撕裂、前囊口收缩、后囊膜混浊等。结论有效前房或睫状体平坦部玻璃体切割是减少手术并发症的关键,前段玻璃体切割、囊袋拉钩联合Cionni张力环植入是伴有前房玻璃体脱出的外伤性晶状体不全脱位较理想的术式选择。

Objective To investigate the effectiveness and safety of anterior vit- rectomy combined with capsular retractor and Cionni modified capsular tension ring （MCTR） in traumatic lens subluxation surgery with anterior vitreous prolapse. Meth- ods This study comprised 15 patients （ 15 eyes） of traumatic lens subluxation with an- terior vitreous prolapse, in which iridodialysis was in 3 eyes, express implantation in 1 eye and Ahmed glaucoma valve implantation in 1 eye. According to the severity of lens subluxation,the patients were divided into three levels, including 90~ - 120~ （7 eyes）, 120~ -180~ （5 eyes） and 180~ -270~ （4 eyes）. Considering the anterior vitreous pro- lapse, anterior vitrectomy or/and pars plan vitrectomy was conducted with assistance of triamcinolone acetonide. After continuous curvilinear capsulorhexis, two to four capsu- lar retractors were placed in the capsulorhexis to support and center the capsule. MCTR was inserted with scleral suture fLxation after phacoemulsification. At last, the foldable IOL was implanted to capsular bag. Postoperative visual acuity, intra- and post-operative complications, anterior capsular opening, IOL positions and intraocular pressure （IOP） were assessed during 3 months＇ follow up. Results All patients had successfully un- dergone phacoemulsification, MCTR insertion and IOL implantation. Seven eyes were in- serted with 2-eyelet MCTR and nine eyes were inserted with 1-eyelet MCTR. The postop- erative visual acuity was better than 0.5 in 9 eyes, between 0.3 and 0.5 in 4 eyes, be- tween 0.1 and 0.3 in 2 eyes,and less than 0.1 in 1 eye. Compared with pre-operation, the difference in the visual acuity was statistically significant （X2 = 17.503 ,P = 0.000 ）. The scheimpflug images obtained from the Pentacam, which demonstrated that the IOL was well centered, and no MCTR and IOL decentration occurred. The common intra- and post-operative complications were residual cortex, aqueous misdirection syndrome, anterior capsular tears, anterior capsular phimosis and posterior capsular opacification. Conclusion The effective application of anterior vitrectomy is the key point to re- duce surgical complications. Anterior vitrectomy combined with insertion of capsular re- tractor and MCTR is an ideal surgical option for patients of traumatic lens subluxation with anterior vitreous prolapse.